GLP-1/GIP Injection Teaching Note

Date/Time: [Encounter date and time]

Patient: [Patient name and identifier per local policy]

Provider/Credentials: [Name, role, credentials]

Learner(s): [patient / caregiver(s) with relationship noted] (List all present.)

Education Method: [demonstration / teach-back / return demonstration / written materials / verbal counseling / video] (Select all that apply.)

Location: [clinic / telehealth / home / other]

Interpreter/Accommodations: [Interpreter modality and language / accessibility accommodations] (Only include if used.)

Indication & Medication

[Reason for education: new start / dose escalation / device change / error correction / caregiver training / reinforcement] — [Medication name and brand; use explicit placeholder if unknown] — [Current dose and frequency] — [Device type: single-dose pen / multi-dose pen / vial and syringe] — [Titration plan if established] — [Medication and supplies in hand: yes/no; specify which items available]. (Do not guess medication identity, dose, or device if not confirmed.)

[Statement that general education was provided; product-specific training will occur once dispensed] (Include only if medication/device not yet finalized.)

Education Provided

[Narrative tailored to specific product: dosing schedule and missed-dose guidance; storage requirements including refrigeration parameters and room-temperature limits; injection technique including site selection, rotation, and device-specific steps; sharps and pen disposal; common GI adverse effects and self-management; red-flag symptoms with escalation thresholds for emergency vs clinic contact; peri-procedural counseling to inform surgical/anesthesia teams of GLP-1 or GLP-1/GIP use]. (Document only what was actually taught.)

[Pregnancy/contraception counseling] (Include only if clinically relevant.) [Hypoglycemia risk and management] (Include only if on concomitant insulin or sulfonylurea.)

[Educational materials provided: manufacturer Instructions for Use, clinic handouts, after-visit summary] (List only materials actually provided.)

Verification

Teach-Back

[What patient/caregiver correctly verbalized: dosing schedule, missed-dose plan, storage, key injection steps, side effect management, red-flag symptoms and when to seek care]. (Record observable statements only. If re-teaching required, note topic and whether understanding achieved after repetition.)

Return Demonstration

[Device used: trainer / actual device] — [Observed actions: site selection, device prep, dose dialing, injection technique, safe disposal] — [Competency level: independent / required cueing / unable]. (Describe only observed behaviors.)

[Reason demonstration not performed and mitigation plan] (Include only if demonstration deferred.)

Plan

[Competency outcome: competent for self-administration / competent with caregiver assistance / needs additional training] — [Next injection or start date and dose] — [Follow-up plan: timing, dose escalation schedule, symptom check-in] — [Supplies confirmed or items still needed] — [Contact information for questions or concerns].